We use technology to seek, store, and measure results. But measurement of productivity in health care is a special challenge. Although we are in the business of healing, health care is an industry, a business that measures outcomes and expects accountability and pro- ductivity. Increases in cost, wide variations in quality, more diverse and better informed patients and consumers, and public and business concerns regarding value for investment have provoked a greater interest in productivity and effectiveness in health care in general across the United States (Shortell, n.d.). Value is what the customer receives for the price paid. To promote efficiency and productivity, Womack and Jones (2005, p. 60) proposed the concept of “lean consumption,” which is when a business provides the full value that customers expect with the “greatest efficiency and least pain.” It requires integrated and streamlined processes and attention to meeting the needs of the customer or patient.
Traditionally, productivity refers to the amount or quality of output per unit of input, a return on investment, or worker efficiency. It is easy to measure the productivity of a machine or even the productivity of labor to produce a product. Healthcare outputs are more vexing. To a large healthcare system in today’s market-oriented culture, productiv- ity may mean its margin of the market. To a hospital worker, productivity may be the timely accomplishment of the day’s duties. Ultimately, the productivity of a national healthcare system must be measured by the health of all its citizens.
From a management and human resources perspective, productivity usually refers to productive hours of human labor, most often referred to as full-time equivalents, or FTEs, or staff workload used in some formula of output. In acute-care systems, outputs are usually measured in some measure related to patient census, acuity levels, patient throughputs, or procedures performed. Other measures include staff turnover related to manager effectiveness.
There is current interest in various formal quality and productivity programs.
Among the most popular are Six Sigma and Lean. These programs are focused toward
manufacturing production but are growing in use in large healthcare systems and hospi- tals (American Society for Quality, 2009). Their hope is based in improving quality and decreasing cost, with a focus on work processes. Six Sigma is “a disciplined data-driven approach and methodology for eliminating defects” (Six Sigma, 2010). The program uses jargon such as titles of “champion” for leaders and awards of “belts,” such as “green belt” and “master black belt” status. The management approach is driven by outcomes data, usually financial, and based on projects to improve processes by controlling varia- tion and improving predictability. Lean is “a systematic approach to identifying and eliminating eight “wastes” through continuous improvement by flowing the product at the 100% pull of the customer” (Lean, 2005). Systems measure productivity by reducing waste of time and human resources for a “lean” journey of the patient across care set- tings facilitated by efficient coordination of care (Kim, Spahlinger, Kin, Coffey, & Billi, 2009). Principles are that all work is process, that process flow can be optimized, and that employee flexibility increases productivity and reduces waste. The eight wastes of lean are waiting, defects, extra processing, inventory, excessive motion, transportation, over- production, and under-utilized employees. An increasing number of such outcomes- based measures are considered in a context of productivity. The long-term value of such programs in human healing organizations remains to be determined. Effectiveness is reflected by accomplishment of mission, goals, and outcomes and satisfaction by all con- cerned, including and especially the people we serve. The danger of a focus on efficiency, in its usual sense, in health care is its potential effects on quality and patient satisfaction, not to mention pushing out the goals of healing and well-being, which have some human subjective, reflective, and social characteristics that challenge productivity measurement.
Productivity and effectiveness must ultimately refer to a focus on value.
The Mayo Clinic Policy Center (2007) identified six action principles to assure produc- tivity in health care for the future: (1) develop a definition of value based upon the needs and preferences of patients, measureable outcomes, safety, and service, compared with the cost of care over time; (2) pay providers based on value and develop a methodology for allocating finite resources; (3) create competition around results through pricing and quality transparency; (4) hold all sectors in health care accountable for reducing waste inefficiencies; (5) create a trusted mechanism to synthesize scientific and clinical informa- tion in an impartial and rigorous way for both consumers and providers; and (6) encour- age formation of integrated systems to deliver effective and appropriate care.
The future will require increased knowledge, facility, and creativity by all leaders in health care regarding how to integrate important business and market principles into the enterprise of healing. We will need to move beyond safety and efficiency toward value and excellence.
The leader who promotes productivity and fosters effectiveness continually sends a message of clear intention and expectations of what is expected and when it must be produced. He or she instills a sense of ownership of goals, processes, and outcomes.
Even detractors must know what are the goals, the work, and the desired outcomes of the organization. In business, effectiveness is often associated with the concept of execu- tion. Execution is the action of getting things done. It requires careful match of people with processes and tasks that come together for highest performance and best results.
All does not always go as planned, but the leader guides the team through continuous improvement and recovery. The leader is also the key person to clearly articulate desired outcomes in a manner that can be identified and measured.
Why do some good organizations fall short of acceptable productivity and effective- ness? Leaders, beware of some habits that can quash the spirit to produce. Overplanning and overmeasuring can kill the spirit, especially in health care. We are in it because we want to help people. We need time to reflect, to cherish our contact with those we serve, and to create. Overplanning, overprocessing, and overproceduring can be devastating.
Good leaders hold people accountable, then guide them toward success, recognize that success, and celebrate it.
Effective practice design and management for the future will consider innovative mod- els, embracing an entrepreneurial context. Such designs must include continual assess- ment at the local unit and entire systems level, decisions based on evidence, effective use of technology in all areas of patient care, and creative ways of measuring effectiveness that improve the efficiency of the system while promoting environments of healing.
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